Tesi Catarina de Oliveira.pdf HIPNOSIS PARA EL DOLOR

PAIN AND HYPNOSIS.

Catarina de Oliveira Tom Lopes Pires

Dipsit Legal: T 1657-2014

ADVERTIMENT. L'accs als continguts d'aquesta tesi doctoral i la seva utilitzaci ha de respectar els drets de la persona autora. Pot ser utilitzada per a consulta o estudi personal, aix com en activitats o materials d'investigaci i docncia en els termes establerts a l'art. 32 del Text Refs de la Llei de Propietat Intellectual (RDL 1/1996). Per altres utilitzacions es requereix l'autoritzaci prvia i expressa de la persona autora. En qualsevol cas, en la utilitzaci dels seus continguts caldr indicar de forma clara el nom i cognoms de la persona autora i el ttol de la tesi doctoral. No s'autoritza la seva reproducci o altres formes d'explotaci efectuades amb finalitats de lucre ni la seva comunicaci pblica des d'un lloc ali al servei TDX. Tampoc s'autoritza la presentaci del seu contingut en una finestra o marc ali a TDX (framing). Aquesta reserva de drets afecta tant als continguts de la tesi com als seus resums i ndexs. ADVERTENCIA. El acceso a los contenidos de esta tesis doctoral y su utilizacin debe respetar los derechos de la persona autora. Puede ser utilizada para consulta o estudio personal, as como en actividades o materiales de investigacin y docencia en los trminos establecidos en el art. 32 del Texto Refundido de la Ley de Propiedad Intelectual (RDL 1/1996). Para otros usos se requiere la autorizacin previa y expresa de la persona autora. En cualquier caso, en la utilizacin de sus contenidos se deber indicar de forma clara el nombre y apellidos de la persona autora y el ttulo de la tesis doctoral. No se autoriza su reproduccin u otras formas de explotacin efectuadas con fines lucrativos ni su comunicacin pblica desde un sitio ajeno al servicio TDR. Tampoco se autoriza la presentacin de su contenido en una ventana o marco ajeno a TDR (framing). Esta reserva de derechos afecta tanto al contenido de la tesis como a sus resmenes e ndices. WARNING. Access to the contents of this doctoral thesis and its use must respect the rights of the author. It can be used for reference or private study, as well as research and learning activities or materials in the terms established by the 32nd article of the Spanish Consolidated Copyright Act (RDL 1/1996). Express and previous authorization of the author is required for any other uses. In any case, when using its content, full name of the author and title of the thesis must be clearly indicated. Reproduction or other forms of for profit use or public communication from outside TDX service is not allowed. Presentation of its content in a window or frame external to TDX (framing) is not authorized either. These rights affect both the content of the thesis and its abstracts and indexes.

Catarina de Oliveira Tom Lopes Pires

Pain and Hypnosis

DISSERTATION THESIS

Supervisor

Dr. Jordi Mir

Department of Psychology

Tarragona, 2014

UNIVERSITAT ROVIRA I VIRGILI PAIN AND HYPNOSIS. Catarina de Oliveira Tom Lopes Pires Dipsit Legal: T 1657-2014

This is to certify that:

The Present Dissertation: Pain and Hypnosis, presented by Catarina de Oliveira Tom Lopes

Pires, has been supervised by Jordi Mir Martinez, Professor at the Departament of Psychology

of the Universitat Rovira i Virgili, in Fulfilment of the Requirements for the degree of Doctor of

Philosophy.

31st of March 2014, Tarragona

____________________________

Jordi Mir Martnez, PhD


Aos meus pais, Carlos e Ilda

minha irm, Ana

Ao meu companheiro on the road, Lus


ACKNOWLEDGEMENTS

There are uncountable people that for uncountable reasons I want to thank for their

unconditional support, help, empathy, encouragement, trust, belief... (this list is endless). Sincerely, my

dissertation work would be so much different without these people who during these years of my life

always stood by me! This dissertation work was a really on the road investigation process, in which I

had the great opportunity to contact with people from different backgrounds and subjects, expertises,

who overtly freed up their attention and knowledge.

Special thanks go to my dissertation thesis` supervisor, Dr. Jordi Mir, who gave me the great

opportunity to develop work in the University Rovira i Virgili, particularly in the ALGOS group. Your

expertise in the field of pain gave me the amazing change to study and investigate such an interesting

topic area as pain in a very stimulating manner. Thank you for your knowledge, trust in my work and

encouragement, Jordi!

I want to thank the Fundao para a Cincia e a Tecnologia (FCT, Portugal) for conceiving me a

pre-doctoral fellowship, which gave the opportunity to develop and conduct research in the University

Rovira i Virgili.

Special thanks go to my parents who always believed and supported my work. You gave me the

wings to fly and to break through. Without you I couldn`t be here and accomplished my present work.

You made the saying by Richard Bach There is no such place as far away completely right as despite

the distance I always felt you very close and attentive. Finally, thanks for your great patience and for

understanding the late nights studying or working during holidays (sometimes you would kidnapped

me!!)! Ilda, thanks for your comforting words in hard moments, your love and empathy, your great and

tasty food dishes (cause the brain also needs nice food to carry on and get stimulated) that you

prepared every time I went back home or when you were in Barcelona... Carlos, thanks for your love and

empathy, your comforting words in moments of less strength, your humour, and your

academic/scientific expertise and advices, and ego-strengthening suggestions for achievement (doing

hypnosis?!) in the development of my work. You`re my favourite scientist!


Special thanks go to my sister, my beautiful poppy, for her personal and professional optimist

and encouragement. For several years, when we lived together in Barcelona, you were my true daily

confident always there to listen to my ideas, feelings and thoughts, troubles and worries, fantasies

and delusions. Now even though you are in another Continent (Uruguay) you`re always present. We

both know that the Atlantic that separates us is just a metaphor...you`re always here! Thanks for your

patience and insights as also a research psychologist.

This work was also not possible without my great colleagues of ALGOS group, Elena, Ester, Eli,

Roco, Roman, Anna, Pere. You were there in the good and less good moments. The humour and

empathy were essential in those moments! I will never forget our Friday`s catharsis afternoons

(remember the PhD chronic syndrome that we worked on?)... For sure, you were my on the road

buddies! Thanks also for the Spanish and Catalan classes and for supporting me in so many ways.

Expression such as buen trabajo, chicas/os or que es eso? are immortalized for me...as well as the

dirty coffee cups, the PMs (pastillas motivacionales, motivation pills), and the constant/chronic

material forgetfulness (a classic!)!

Special thanks to Dr. Bernhard Trenkle for welcoming me as stage student in the Milton Erickson

Institute (MEG, Rottweil, Germany) for 3 months. In the MEG I had the fantastic opportunity to meet

and contact with experts, researchers and clinicians from Germany, Austria, Switzerland, Poland and

USA using hypnosis. This small village, in fact, was a very stimulating city. Bernhard you are a very

inspiring person and your passion on hypnosis was really contagious. Special thanks to Dr. Melchior who

was also my supervisor in the Institute. We spent hours and hours debating about hypnosis and pain.

Thanks for believing and supporting me so much and in so many ways. Thanks also to Sebastian who

always had a huge smile in his face and was ready to help. We all had great Giovanni`s moments

surrounded by the amazing Black Forest, huge German sausages, and schwarzbier.

All my work during this dissertation project counted with many people, such as the participants

in the experiment on migraine I`d conducted in the Unity for the study and treatment of pain (ALGOS

group) between 2010 and 2012. Without them I could not contribute to migraine research. Thanks again

for your availability and motivation to participate in the experiment.


Special thanks to people who helped with my dissertation work, such as Dr Albert Viad, Dr Jose

Marco, who kindly gave me lectures on the electrodermal activity and its measurement, and also to Dr

Joan Ferrando for his statistical advices.

I spent do many hours in the Catalunya Library that I ended up meeting and be friend of several

researchers also doing the PhD. It was very comforting and energetic to be gathered with people aiming

to do a dissertation thesis, in such a stimulating environment as this beautiful and ancient library.

Special thanks for all of you and good luck.

Special thanks to my on the road partner, Lus. We met years ago and we always have been

good friends. However, was the PhD and the hours spent on the library side by side, in which we

motivated each other to carry on our work somehow that brought me close to you. So, in between

books, articles, pens, and pencils we finally met, Lus. Thanks for your love and support and for never

doubting on my work.

Special thanks also to all my friends around the world, but in particular to the ones that more

closely stood by me with their friendship and comforting sounds: Pipinha, Tnia, Ricardo, Maria Joo,

Nini, Velouria, Pedro, Bruno, J, Fulvio, Mafalda, Ins, Snia, Daniel, Joana, Adriana, Cesare, Helder,

Carola, Sonja, Gachi, Chini, Diego, Irina, Menia. Thanks Fulvio for your amazing artistic hands, which

drew the front cover of the thesis. Special thanks also to the rest of my family for their great support

and motivation, my grandmothers (Nomia and Teresa), uncles, cousins, Maria, Moiss, Aron and

Pablito (my little brother). Thanks for everything!

Once again, thank you all!


INDEX

I. INTRODUCTION...................................................................................................... page 1

1. On the experience of pain.................................................................................. page 1

1.1. Defining pain....................................................................................... page 1

1.2. Acute pain versus chronic pain........................................................... page 2

1.3. Chronic pain........................................................................................ page 4

1.4. Chronic pain and psychophysiological variables................................. page 5

2. Migraine......................................................................................................... page 8

2.1. Defining migraine............................................................................... page 8

2.2. Migraine in numbers and figures: extension and

burden................................................................................................ page 9

2.3. Migraine triggers............................................................................... page 10

2.4. Migraine and psychophysiological

variables............................................................................................ page 13

3. Hypnosis........................................................................................................ page 16

3.1. Defining Hypnosis.............................................................................. page 16

3.2. Hypnosis as a pain control technique................................................ page 16

3.3. Hypnosis in the management of chronic pain in children and its clinical use

by health professionals..................................................................... page 18

3.4. Underlying mechanisms in hypnosis................................................ page 21

II. OBJECTIVES.......................................................................................................... page 25


III. METHOD............................................................................................................... page 29

1. Participants.................................................................................................... page 31

2. Procedure...................................................................................................... page 32

3. Measures....................................................................................................... page 33

IV. RESULTS................................................................................................................ page 35

1. Study I: Electrodermal responses and memory recall in migraineurs and headache-

free controls.......................................................................................................... page 39

2. Study II: Hypnosis for the management of chronic and cancer procedure-related

pain in children..................................................................................................... page 65

3. Study III: Use of hypnotic techniques in children and adolescents with chronic pain:

do age of patients, and years of practice and theoretical orientation of clinicians

matter?................................................................................................................ page 93

4. Study IV: Expectancies and hypnotic responsiveness: an experimental design flaw

revealed.............................................................................................................. page 115

V. GENERAL DISCUSSION........................................................................................ page 137

VI. CONCLUSIONS.................................................................................................... page 155

VII. REFERENCES..................................................................... .................................. page 159


I. INTRODUCTION


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1. On the experience of pain

1.1. Defining pain

Pain is a universal experience (Kleinman et al., 1992). Pain is phenomenological at its

core, which means that it is fundamentally a subjective and private experience (Pincus &

Sheikh, 2009). For at least 30 years, pain has been scientifically defined by the International

Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such

damage(Merskey et al., 1979). Additionally, in the last fourteen years, pain has been

conceptualized as a fundamental component of the body`s defence system (World Health

Organization, WHO, 2000) as pain impels the individual to search for relief from the unpleasant

noxious stimulus. Pain is ubiquitous and essential for survival (Turk & Melzack, 2011), being

the most common complaint and symptomatic reason to seek medical consultation. Pain is

one of the largest moneymakers for the world`s health-care industry, and it is a prevalent and

costly problem in children, adolescents, and adults (e.g., Huguet & Mir, 2008; Langley et al.,

2011; Perquin et al., 2000). An estimated 6.10 million (17%) of the adult population of Spain

reported experiencing pain in the last month with daily pain being experienced by 7% of the

population (Langley et al., 2011), whereas in children (8-16 years old) 37% reported having

chronic pain and 5% moderate to severe chronic disabling pain (Huguet & Mir, 2008).

The IASP definition emphasizes the role of affect as an intrinsic component of pain; i.e.

pain is always subjective and always unpleasant. However, pain has been considered for the

most part an inevitable sensory response to tissue damage with little room for the affective

dimension, and none whatsoever for the effects of genetic differences, past experience,

anxiety or expectations (Loeser & Melzack, 1999). Pain researchers recognize that pain has

both sensory and emotional features as well as an ability to command attention and dominate

other cognitive processes (Chapman & Nakamura, 1999). Accordingly, pain is multidimensional

with growing evidence showing that pain is a complex perceptual experience influenced by a


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wide range of psychosocial factors, including emotions, social and environmental context,

sociocultural background, the meaning of pain to the person, beliefs, attitudes, and

expectations, as well as biological factors (Turk & Okifuji, 2002). The experience of pain and its

meaning appears to change across situations and cultures as well as over time; cross-cultural

studies prove the existence of differences in pain perception thresholds (Curtis, 2000; Mir,

2003). In recent years, great advances have been made in our understanding on the

mechanisms that underlie pain and in the treatment of people with pain. Pain is a great

challenge in terms of its explanation, biological meaning, psychosocial impact and

interference, and treatment.

A number of contributions from psychologists have helped to shape the modern

definition and conceptualization of pain, as pointed by Mir (2003). Firstly, the contribution of

the development of the gate control theory (Melzack & Wall, 1965), secondly, the research

work claiming the influence of psychological factors in the physiological activity implicated on

the genesis of the pain problem (e.g., Blanchard et al., 1980), and finally, research pointing to

the role of operant conditioning processes in the experience of pain (e.g., Fordyce et al. 1968).

1.2. Acute pain versus chronic pain

There are different ways of classifying pain, for example, in terms of its location (e.g.

lower back pain, dental pain, joint pain, pain in the neck, headache, etc), or its cause (e.g.

inflammatory pains, neuropathic pain related to nerve damage, central pain related to

information processing in the central nervous system). Another very important dimension that

is used to classify pain is time (i.e. duration of pain), as in chronic pain, which lasts a long time,

versus acute pain, which is shorter in duration. Examples of acute pain is procedural pain,

which arises from some medical treatment, for example, following knee surgery (e.g. Cupal &

Brewer, 2001), cancer treatments (e.g. Syrjala & Roth-Roemer, 1996) or childbirth (e.g.

Achterberg et al., 1994). On the other side, chronic pain can be defined as pain that persists, at


INTRODUCTION

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least for 3 months, and that resists conventional pain treatments. Merskey and Bogduk (1994)

define chronic pain as pain which persists past the normal time of healing. (...). In practice this

may be less than one month, or more often, more than six months. For chronic back pain the

usual time is 6 months, whereas in post-herpetic neuralgia 3 months of persisting pain is the

more common time point at which the condition is dubbed chronic. Apart of this temporal

distinction, there a number of features that allows us to distinguish acute from chronic pain. In

terms of prevalence, acute pain seems to be more prevalent than chronic; which in fact has a

biological meaning (i.e., it is useful as a warning signal) while chronic pain has no function, it is

useless. Furthermore, in acute pain the cause is typically known whereas in chronic pain most

of the time the cause is unknown, the beginning of acute pain seems to be more defined than

in chronic pain, and in terms of treatment, in acute pain the cause (i.e. aetiology) is in focus,

while in chronic pain a multidisciplinary intervention is in request. Therefore, with different

biological meanings or functions, acute and chronic pain lead to different therapeutic

approaches as they have a distinct psychological, biological, social, emotional, and cognitive

impact. A key distinction between chronic and acute pain is the relationship the person

creates with the pain. Pain is a familiar, emotionally-charged, meaning-laden, unwelcome, yet

inevitable visitor for all individuals. As illustrated by Pincus and Sheikh (2009), the meaning of

such a visit (i.e. pain) is completely different, if it is for an afternoon versus a weekend, if pain

is going to stay only for tea, or if it is going to tag along with everything we do. Therefore, the

distinction between acute and chronic pain is far deeper than an issue of duration.

Psychological factors play an important role in the experience of pain, being argued that

chronic pain interferes at a great extent on those variables and vice-versa, which requires

demanding therapeutic strategies not only for pain control, but also for the impact that

chronic pain has on the individual (in a number of different levels).


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1.3. Chronic pain

Chronic pain is a major health problem, and hence, it might be expected that chronic

pain would be well treated and under control; however most forms of chronic pain are poorly

understood, and even when they are understood, the severity may not be adequately

managed (Turk & Melzack, 2011). A large European survey revealed that chronic pain of

moderate to severe intensity occurs in 19% of adults, seriously affecting the quality of their

social and working lives. Results of the survey also showed that very few were managed by

pain specialists and nearly half received inadequate pain management (Breivik et al., 2006).

Thus, the impact of chronic pain proved to be high as revealed by the statistics: 66% had

moderate pain (numerical rating scale - NRS = 57), 34% had severe pain (NRS = 810), 46%

had constant pain, 54% had intermittent pain. Fifty-nine percent had pain for two to 15 years,

21% had been diagnosed with depression because of their pain, 61% were less able or unable

to work outside the home due to pain problems, 19% had lost their job, and 13% had changed

jobs because of their pain. Sixty percent visited their doctor about their pain 29 times in the

last six months. One-third of the chronic pain patients were currently not being treated. Two-

thirds used no medication treatments, e.g. massage (30%), physical therapy (21%),

acupuncture (13%). Therefore, pain that persists for months and years, i.e. chronic pain, will

influence all aspects of a persons functioning: emotional, interpersonal, vocational, and

physical. Consequently, successfully treating chronic pain patients requires attention not only

to the physical basis of the problem but also to the range of factors that modulate nociception

and moderate the pain experience and related disability (Turk & Okifuji, 2002). In this process,

integrating the care and interventions within a biopsychosocial framework is fundamental. The

biopsychosocial model explains pain as a complex experience resulting from the interaction

and influence of a number of factors, such as biological-physical (physiological, genetic),

psychological (cognitive, emotional) and social (behavioural, professional and cultural) (Mir,

2003, 2008).


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1.4. Chronic pain and psychophysiological variables: electrodermal activity and cognitive biases

Psychophysiological measures are primarily used as a tool to determine the influence of

psychological factors in body functioning, and specially, to measure their contribution to the

initiation and maintenance of symptoms. In many chronic pain syndromes, psychophysiological

factors play a major role in the development and or maintenance of the problem (Flor & Turk,

2006). Overall, available studies suggest that responses to painful stimuli seem to be

associated with characteristic peripheral physiological responses in the muscular, vascular and

eccrine system (Flor & Meyer, 2011). Chronic pain patients have an extended history of

frequent and strong connections between physiological response elements and meaning

elements of pain (Bonnet & Naveteur, 2006). Hence, psychophysiological measures are of

primary importance in the assessment of chronic pain syndromes, and are increasingly gaining

importance in clinical pain research (Flor & Meyer, 2011). Initial attempts to measure

psychophysiological concomitants of pain were undertaken in the 1950`s (e.g., Malmo et al.,,

1950), but only became accepted in the following decade when biofeedback methods came

into broad use. Over the past 60 years, much evidence for the interaction of psychological and

physiological variables in pain has accumulated (McMahon & Koltzenburg, 2005). However,

much of the research related to the psychophysiology of pain still lacks adequate theoretical

foundation and methodological rigor (cf. Apkarian et al., 2005; Flor & Turk, 1989), which

represents a challenge for future research.

Psychophysiological data is of great importance as it serves a number of useful functions

in the evaluation of acute and chronic pain states (Flor & Meyer, 2011); that is, they provide

evidence on the role of psychological factors in maladaptive physiological functioning in

specific patients, and may serve as predictors of treatment outcome (Flor & Birbaumer, 1993;

Harris et al., 2008; Walitt et al., 2007). In experimental pain research, psychophysiological data

have been used to examine concomitants of anxiety and general arousal associated with pain

(Flor & Meyer, 2011). They have also served as measures of central processes related to pain


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experience. It has been demonstrated that electrodermal activity (EDA) may be a useful

autonomic indicator of sensitivity to pain (Dowling, 1982), reflecting the reactive component

of the pain experience (Fowles, 1980). Skin conductance may be viewed as a measure of

general arousal as it changes with the activation of the sweat glands that are responsive to

psychological stimuli (Fowles, 1986). Their activity is mediated by the sympathetic nervous

system. Often-used parameters of the sympathetic activity of the skin are the tonic skin

conductance level or the phasic skin conductance response. Interest in this measure for the

pain field comes from evidences showing that: (1) EDA reacts to pain in healthy volunteers

(Baltissen & Boucsein, 1986; Dowling, 1983; Waid, 1979; Reeves, 1982) and chronic pain

individuals (hman, 1972; Passchier & Orlebeke, 1983; Peters et al., 1989; Peters & Schmidt,

1989); (2) modification of EDA through the application of classical conditioning procedures is a

reliable phenomenon (hman, 1972).

Findings on the significance of skin conductance measures for chronic pain have been

controversial. As pointed by Flor and Meyer (2011), further research is needed to determine

the role of peripheral psychophysiological variables in chronic pain. For example, Peters and

Schmidt (1991) found enhanced skin conductance levels in response to stress in patients with

chronic low back pain, but these results were not confirmed by Flor and colleagues (Flor et al.,

1985, 1992). A number of studies on clinical pain research revealed that chronic pain patients

significantly report increased electrodermal activity upon the presentation of pain questions

(Salamy et al., 1983), and pain descriptors relevant to the patients` pain problem (Flor et al.,

1997; Jamner & Tursky, 1987; Chapman & Martin, 2011). Such a different psychophysiological

responsivity might serve as a basis for the early recognition of chronic pain and the detection

of malingering (Salamy et al., 1983). Specifically, migraine episodes have been suggested to be

related and somewhat maintained by highly specific conditioning or sensitization to pain-

related stimuli (Jamner & Tursky, 1987). However, highly and unique specific conditioning to

pain-related stimuli is still a debatable question (Knost et al., 1997; Larbig et al., 1996; Bonnet


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& Naveteur, 2006). Further on, we will describe in greater detail the relationship between

electrodermal activity and migraine. Although the relationship between physiological

responses and meaning elements of pain is defended by a number of authors, it has been

scarcely studied. In migraine pain, for example, only one study covered this matter (Jamner &

Tursky, 1987).

On a cognitive level, individuals with chronic pain have been found to exhibit specific

memory and cognitive bias (i.e., interpretation biases or the tendency to interpret ambiguous

stimuli and situations in a threatening fashion) for pain related material (Edwards & Pearce,

1994; Pearce et al., 1990; Pincus et al., 1993, 1995, 1996). Attentional bias (i.e., selective

attention to threat-related stimuli presented at the same time as neutral stimuli) for pain-

related stimuli has been observed in chronic pain patients (Beck et al., 2001; Dehghani et al.,,

2003, 2004; Pearce and Morley, 1989). Moreover, a series of recent studies (Liossi et al., 2009;

Liossi, White & Schoth, 2011; Schoth & Liossi, 2010) confirmed an attentional bias for pain-

related words in chronic headache patients, supporting the content-specificity hypothesis, i.e.

attentional bias was only presented towards pain-related cues (not for social threat, anger-

threat and neutral stimuli). However, this relationship is still on debate (Asmundson et al.,

1997; Asmundson & Hadjistavropoulos, 2007; Dear et al, 2011; Roelofs et al., 2002).


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2. Migraine

2.1. Defining migraine

In the last 50 years vascular changes were considered the primary cause of migraine

giving a very important role to the Central Nervous System (CNS) (Blau, 1987). However, the

aetiology of migraine has been under debate. Nowadays the vascular theory of migraine

appears to be scarcely adopted as migraine is now considered primarily a neurological

disorder that secondly affects the blood vessels. Prior to the 1980s, there was little consensus

about headache classification and diagnosis (Andrasik et al., 2011). However, in 1988, a

classification system was finally created by the International Headache Society; i.e.

International Classification of Headache Disorders (ICHD). This classification system was

revised and updated in 2004 (see Table 1). Migraine is a complex type of headache that

accounts for a fair number of body changes and distinct phases. Five phases have been

described as part of migraine episodes (Blau, 1987; MacGregor, 2006), such as: (1)

premonitory symptoms, (2) aura, (3) headache, (4) recuperation, (5) postdromal symptoms.

The premonitory symptoms, both excitatory or inhibitory, relate to subtle neurological, (e.g.,

sensibility to light or concentration problems), behavioural (e.g., hyperactivity or tiredness),

physical (e.g., pale face or chills), gastrointestinal (appetite for certain food and constipation),

psychological (e.g., irritability and sadness, depression) and cardiovascular changes (e.g.,

tachycardia and bradycardia) that occur some hours or even a day before the beginning of the

migraine episode. In respect to the second phase of migraine, aura symptoms may include

seeing flickering lights, spots or lines, loss of vision, feeling of pins and needles or

numbness. This phase distinguishes two types of migraine; i.e. with and without aura.

Migraine with aura is defined as a focal neurological disturbance manifest as visual, sensory or

motor symptoms (IHS, 2004). Approximately 20% of migraineurs experience aura,

characterized by focal neurological features that usually occur in the hour preceding the

headache (Andrasik et al., 2011). Phase three relates to headache, which tend to be moderate


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to severe pain that lasts at least 4 hours, and is often unilateral with a pulsing quality, and

may be aggravated by movement and activity. Associated symptoms may occur such as

nausea, vomiting, vertigo, phonophobia (sensibility to sound) and photophobia (sensibility to

light). Finally, the last two phases emphasise how the migraineur overcomes the migraine

episode (e.g. sleeping, taking pain killers, vomiting), and the hangover symptoms, which

commonly are: humour changes, tiredness, limited tolerance to food, itchy muscles,

occasional diuresis (Sandler & Collins, 1990).

Table 1. International Headache Society Migraine Diagnostic Criteria (2004)

2.2. Migraine in numbers and figures: extension and burden

Although most headaches are benign, they can have a significant negative impact on

functioning, productivity and quality of work, imposing a substantial burden on individual

headache sufferers, on their families and on society (Andrasik et al., 2011). Stovner et al.

1 1.2.1. Typical aura with migraine headache, 1.2.2. typical aura with non-migraine headache, 1.2.3. typical aura without headache, 1.2.4. familiar hemiplegic migraine (FHM), 1.2.5. sporadic hemiplegic migraine, 1.2.6.basilar-type migraine

Diagnostic criteria for migraine without aura according to the International Headache Society (IHS, 2004)

Diagnostic criteria for migraine with aura according to the International Headache Society (IHS, 2004)

A . At least 5 attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C. Headache has at least two of the following characteristics:

1. unilateral location

2. pulsating quality

3. moderate or severe pain intensity

4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

D. During headache at least one of the following:

1. nausea and/or vomiting

2. photophobia and phonophobia

E. Not attributed to another disorder

A. At least 2 attacks fulfilling criteria B

B. Migraine aura fulfilling criteria B and C for one of the subforms 1.2.1 1.2.61

C. Not attributed to another disorder


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(2007) reviewed population studies for migraine, tension-type headache and chronic daily

headache and estimated that the worldwide prevalence was 47% for headache, 10% for

migraine, 38% for tension-type headache, and 3% for chronic daily headache. Further, lifetime

prevalences were somewhat higher for headache (66%), migraine (14%) and tension-type

headache (46%). In migraine, most large studies generate estimates in the 15%-20% range for

females and 4%-7% range for men (Lipton et al., 2008). Most studies of migraine report that

prevalence is higher in females at all post-pubertal ages and that it also varies according to age

(i.e. prior to puberty, the prevalence of migraine is slightly higher in boys than in girls);

migraine prevalence is at its highest between 25 and 55 years of age, typically the peak

productive years of life (Lipton, Diamond, et al., 2001; Lipton, Stewart et al., 2001; Lipton et al.,

2002; 2007). As pointed by Lipton et al. (2008), in the adult population, in every region of the

world, and in every racial and ethnic group studies, migraine is two to three time more

common among females than males.

2.3. Migraine triggers

According to the International Headache Society (IHS, 2004), migraine triggers increase

the probability of having a migraine attack in the short term (usually

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McGregor (2006), 79% of the migraineurs were able to identify their pain triggers, and the

most common ones were stress, hormones, tiredness and hunger. Similar results were

observed by Kelman (2007) reporting that 75% of the migraineurs were able to identify their

migraine triggers, with the most common ones being stress, hormones, hunger, weather

changes, sleep problems, strong smells, neck pain, lights sensibility, alcohol, smoke of

cigarettes, heat/hot temperatures, food, exercise, and sexual activity. The majority of

migraineurs, in Macgregors study (2006) mentioned that a number of triggers were necessary

to together induce a migraine episode. Accordingly, a migraine threshold determined by the

genetic constitution of people has been proposed (see Figure 1). Pearce (1987 in Blau, 1987)

and Welch (1990) had also suggested the existence of a threshold in the Central Nervous

System (CNS). The migraine threshold appears to be enhanced or diminished due to external

factors (e.g., stress), but also by brain internal changes. Granted that a certain number of

triggers are needed to reach such a threshold, this would explain why a similar situation not

always leads to a migraine episode (MacGregor, 2006).

For example, stress is a commonly referred migraine trigger. However, according to

Barber (1996), there is no scientific support to that migraine is a result primarily of

psychological factors, even though he recognizes the role of stress in the aggravation of the

problem. The IHS refers to psychological stress as an aggravating factor rather than a trigger or

precipitant of migraine. Examples of commonly-reported aggravating factors include:

psychosocial stress, frequent intake of alcoholic beverages, other environmental factors. The

relationship between stress and headache has long been reported in the literature (Henryk-

Gutt & Rees, 1973; Howarth, 1965). Stress can change the interactions between the

neuromatrix and peripheral stimuli, as can learned experiences and expectations (Loeser &

Melzack, 1999). For any given person with headache, stress most probably operates in multiple

ways and in concert with other, various biological influences. Negative thoughts and emotions

emerging from the repeated experience of headache can become further stressors or trigger


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12 | P a g e

factors in and of themselves (referred to as headache-related distress), serving at that point

both to help maintain the disorder and to increase the severity and likelihood of future

attacks. The biopsychosocial model of headache suggests that biological, psychological and

social factors and their interaction all play significant roles in the experience and outcomes of

headache disorders (Andrasik et al., 2005). Specifically in the case of headache, biological and

pathophysiological predispositions and mechanisms may be triggered by the interplay of the

individual`s physiological status (e.g., level of autonomic arousal) with environmental factors

(e.g., stressful events, certain food, alcohol, toxins, hormonal fluctuations), and sequential

factors that may serve to reinforce, and thus increase, the person`s probability of reporting

head pain (Wagoner & Andrasik, 1990). Psychological factors do not play a causal role per se;

rather they contribute to headache in various ways, such as: (1) triggering factors, (2)

maintaining factors, (3) exacerbating factors, and (4) sequelae to continued head pain and

subsequent life disruption (Andrasik et al., 2011).

Table 2. Migraine triggers (Silberstein et al., 2008)

MIGRAINE TRIGGERS

Diet Hunger, alcohol, additives, certain foods

Hormonal changes Menstruation

Chronobiologic changes Sleep (too much or to little), schedule change

Environmental factors Light glare, odours, altitude, weather change

Head or neck pain Or another cause

Physical exertion Exercise, sex

Stress and anxiety Letdown

Head trauma -


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Figure 1. Migraine Threshold (taken from MacGregor, 2006)

2.4. Migraine and psychophysiological variables: electrodermal activity and the role of memory

In the early 90s, a number of theoretical explanations from the Psychology field had

emerged which intended to give a better understanding of migraine (e.g. bio-behavioural

theory by Joseph and Welch, 1987, 1990; imagetic bio-absorption theory IBT - by Pires,

1990). The IBT explains migraine as both a memory and a psychophysiological deregulation

problem (Pires, 1990; 2002). The main IBT basic assumptions are that: (1) migraine`s

psychological activity is organized in schemes or patterns cerebrally controlled; (2) such

patterns are kept in memory like prepositions; and (3) in proper conditions, such patterns or

programs can be unchained, leading to a migraine episode. Then, the proper conditions act like

mnemonic stimuli and such patterns and program may be triggered leading to a migraine

episode. A possible memory for migraine pain is on the centre of the debate. According to

Lang (1979), the bio-memories are related to a propositional pattern that includes information

in respect to environmental, psychological, and biological oscillations. The IBT bases its

theoretical framework on previous research work, such as the mentioned Bio-informational

theory of emotional imagery (Lang, 1979), and research work on psychophysiological variables


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related to migraine (Jamner & Tursky, 1987). The Bio-informational theory of emotional

imagery Lang (1979) conceives the image or propositional structures in the brain to be a

conceptual network, controlling specific somatovisceral patterns, and constituting a prototype

for overt behavioural expression. The imagetic activities are associated with alterations in the

autonomous nervous system (ANS). Accordingly, emotional response can be measured in at

least three different systems - affective reports, physiological reactivity, and overt behavioral

acts. As formerly mentioned, an altered cognitive processing of pain-related information and

heightened reactivity to pain may contribute to the maintenance and exacerbation of chronic

pain (e.g., Flor et al., 1990; Flor & Birbaumer, 1994; Turk and Flor, 1999). In fact, attentional

bias for pain-related stimuli (Liossi et al., 2011; Liossi et al., 2009; Schoth & Liossi, 2010) was

found in chronic headache patients revealing that both hypervigilance and sustained

processing are critical factors for the maintenance of chronic pain. Specifically, research on

psychophysiological variables shows that migraineurs may be highly conditioned or sensitised

to migraine pain-related stimuli, which imply an emotional processing (Jamner &Tursky, 1987).

This could be the result of the additional significance that pain descriptors have acquired from

their repeated associations with the migraineurs internal pain experience (Jamner & Tursky,

1987). In sum, stimuli that may trigger a migraine can be related to a specific migraine network

or pattern that in turn is activated when considered the three types of information (i.e. stimuli,

meaning and response) in the understanding of the body experience. Furthermore, it is

important to remark that not only pain-related words, but also emotional stimuli might have

an important role in migraine maintenance. Emotional stimuli and emotional states, such as

negative affect, have been suggested as major migraine triggers (Puschmann & Sommer,

2011), and play an important role on the maintenance of migraine. Negative thoughts and

emotions emerging from the repeated experience of headache can become further stressors

or trigger factors in and of themselves (Andrasik et al., 2011). Hence, headaches can be


INTRODUCTION

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maintained or increased through a process of sensitization, failed habituation or lack of

opportunities for learning to cope with the trigger (Martin & MacLeod, 2009).

Conclusively, it is proposed that the brain memorizes migraine-related emotions and

bio-images, which can be modified by the individual through a learning process intending to

change the psychophysiological patterns (Lang, 1987). Therapeutically, the IBT proposes the

modification of the content and structure of an image; i.e. specific problematic migraine-

related bio-images. IBT permits a systematic and deliberated manipulation, through verbal

instructions, of the bio-images of the migraineur. Moreover, it relies not only on the use of

imagination and relevant personal migraine-related images, but also hypnotic-type

suggestions. Edmonston (1981) pointed that specific suggestions can be the active component

of the treatment of migraine. The inclusion of hypnotic-type suggestions in the management

of migraine aims to the modification of pain perception and control of a number of migraine-

related physiological functions (Tom-Pires & Pires, 2009). Hypnosis, which will be the next

topic under discussion, is characterized by a state of high receptivity to suggestions intending

to modify the subjective experience and, for example, teach to control physiological functions

such as the vascular system (Barber, 1996).


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3. Hypnosis

Granted its relevance, in this section we will emphasise the use of hypnosis as a

therapeutic tool for pain management, especially in chronic pain by reviewing and examining

its clinical use. Furthermore, granted that available studies have suggested a number of factors

that should be considered in the explanation of hypnotic response to suggestions, we will

specially address the role of psychological factors, such as hypnotizability, and expectancies, in

hypnosis and hypnotic responding.

3.1. Defining hypnosis

Hypnosis has been conceptualized as a technique that usually contains an induction or

introduction procedure during which the subject is told that suggestions for imaginative

experiences will be presented (Green et al., 2005, p. 262). This inductive procedure is

followed by suggestions for changes in subjective experience, alterations in perception,

sensation, emotion, thought, or behavior (Green et al., 2005, p. 262). In hypnosis, changes in

the subjective experience induced by suggestions occur, and are characterized by mental

facility (relaxation), absorption (attention focus), reduction in the temporal-spacial orientation

and automaticity (Rainville & Price, 2004). Moreover, hypnotic techniques being able to alter

sensory awareness, perception, memory and behavior have the potential to influence

physiological functioning and the course of medical conditions (Pinnell & Covino, 2000).

3.2. Hypnosis as a pain control technique

Hypnosis has had a cyclical history of acceptance and rejection since the time of

Mesmer, two hundred years ago (Hilgard & Hilgard, 1994); frequently misunderstood, poorly

accepted and greatly underutilized. Most health care professionals have little accurate

information about hypnosis, and their attitudes and beliefs are often based on misinformation

(Thomson, 2003). Nevertheless, hypnosis has now attained a significant place in medical and


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psychological science. Accordingly, the scientific foundations upon which the understanding of

hypnosis is based have become much firmer in the last decades (Hilgard & Hilgard, 1994).

In the course of research, much has been learned about the effectiveness of hypnotic

procedures in the relief of pain. Over the past 20 years, a significant body of research has

grown to support hypnosis for the treatment of pain, and in general, scepticism from a

scientific standpoint is no longer warranted (Patterson, 2010). As described by Hammond

(2007), hypnosis meets the criteria for an empirically well established and supported

treatment. Published reports, systematic reviews, and meta-analyses have demonstrated that

hypnosis is effective in the management of pain in adults for acute, chronic, or cancer

procedure-related pain experiences (Castel et al., 2007; Hammond, 2007; Hawkins, 2001; Lynn

et al., ,2000; Jensen et al., 2011; Jensen & Patterson, 2006; Montgomery et al.,2000; Stoelb et

al., 2009). Montgomery et al.`s review (2000) of randomized controlled studies found that

hypnosis produced pain relief in 75% of the population. Findings revealed a moderate-large

effect of hypnosis in both experimental and clinical pain. Furthermore, hypnotic procedures

have been found to produce significantly greater pain reduction in a variety of chronic pain

types comparing with no-treatment/standard care and some non-hypnotic interventions, such

as education/advise, supportive therapy, medication management or physical therapy (Elkins

et al.,2007; Jensen & Patterson, 2006; Stoelb et al., 2009). Besides, the effects of hypnosis as

an adjunct treatment to other treatments for chronic pain, for example standard medical care,

lead to greater pain reduction than those without (e.g., Liossi & Hatira, 2003; Liossi et al.,

2006, 2009). Additionally, research has suggested that hypnosis performs similarly to

treatments that contain hypnotic elements (such as progressive muscle relaxation), but is not

surpassed in efficacy by these alternative treatments (Jensen & Patterson, 2006; Stoelb et al.,

2009).

The effects of hypnosis are gradual and different among individuals; i.e. some patients

are primarily able to reduce their psychological distress associated to pain, while other


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patients can reduce either intensity of pain and pain-related psychological distress (Barber,

1996). The main objective of a hypnotic treatment is not to change pain during hypnosis, but

to give suggestions and teach skills and strategies that will alter pain intensity and its daily

impact effects (Jensen & Patterson, 2006). Hypnosis has beneficial effects both on pain-related

outcomes (e.g. pain intensity, duration, frequency, analgesic medication use), and non-pain

related (e.g. anxiety, sleep, quality of life). As referred by Ordi (2005), the benefits of hypnosis

could be briefly summarized in the following ones: (1) it contributes to the reduction and relief

of pain; (2) its use as an adjunctive tool to other medical and psychological techniques allows

the achievement of successful therapeutic results with less time and effort from the patients;

(3) hypnotic suggestions emphasise positive attitudes in respect to coping and problem

solving, promote the active role of the patient in his/her therapeutic change, make use of

imaginative abilities and rely on an emotional implication, favour the relaxation response, and

finally, lead to quick changes in the patient`s behaviour which in turn enhance his/her

motivation and adherence to treatment. Besides the positive effects that result from the use

of a hypnotic intervention, it is important to note that hypnosis is a very economic pain control

tool, easy to administrate, able to reduce the medication costs in respect to conventional

medical treatments and with no adverse side effects (Hammond, 2007; Kohen & Zajac, 2007;

Tsao & Zeltzer, 2005) or as pointed by Jensen (2013), hypnosis has many side effects that are

overwhelmingly positive.

3.3. Hypnosis in the management of chronic pain in children and adolescents and its clinical

use by health professionals

By the end of the 19th century, those who had studied the field of hypnosis already knew

that children were suitable hypnotic subjects, that the peak of hypnotizability occurred in

middle childhood, and that hypnotic techniques were applicable to a wide variety of childhood

medical and psychological problems (Olness & Kohen, 1996). More modern interest in using


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19 | P a g e

imaginative and hypnotic techniques with children developed in the 1960s and 1970s with the

research and writings of icons in the field, including J. R. Hilgard (1970), Fromm (1972, 1979),

Erickson (1958), Gardner (1974, 1977), Boswell (1962), and Singer (1973, 1974) (Lynn et al.,

2010).

A few controlled studies (e.g. Kellerman et al.,1983; Olness et al.,1987; Vlieger et al.,

2007), non controlled studies (e.g., Anbar, 2001a,b; Kohen & Zajac, 2007) and case studies

(Olness & MacDonald, 1981) confirm the efficacy of hypnosis as a pain control tool in children

and adolescents. Surprisingly, although children and adolescents are considered good hypnotic

subjects (Ollness & Kohen, 1996; Wood & Bioy, 2008), there is very little systematic research

on this matter.

Among the issues that still await clarification or additional studies are, as mentioned by

Jensen and Patterson (2006), a common operational definition of hypnotic analgesia; the lack

of standardization of hypnotic protocols, and the need to identify the components of a

hypnotic intervention. Effects and mechanisms of hypnotic analgesia can be examined by

conducting component and process analyses (Jensen & Patterson, 2006). Component analyses

relate to how hypnotic treatments differ from each other in content (e.g. different induction or

suggestions) or dose (number of treatment sessions). On the other side, process analyses are

performed to identify predictors or covariates of treatment outcome (e.g. hypnotizability,

motivation, relaxation, dissociation) (Jensen & Patterson, 2006). For example, hypnotizability,

that is, a persons ability to experience and respond to hypnosis in general, has been suggested

as a predictor of positive treatment outcomes (e.g., Jensen & Patterson, 2006; Hawkins et al.,

1998) and of clinical relevance in diminishing patient`s response to pain (see Chaves, 1989).

Therefore, knowledge on the hypnotic effects requires the need to determine, for

example, the extent to which there is a dose effect for hypnotic analgesia as well as a content

effect (Patterson & Jensen, 2003), and test the nature of the hypnotic suggestions. Future

studies could benefit from identifying when, for what, and for whom a hypnotic intervention is


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appropriate and whether it should be administrated alone or in combination with other

techniques.

Similarly, another area that deserves additional effort is that of how hypnosis is

delivered. For example, what are the specific features of a hypnotic session that make them

successful in the context of pediatric chronic pain? Although hypnosis has proven efficacy in

the treatment of chronic pain in young patients, the treatment encompasses a large variety of

techniques, some of which might be more effective than others. Knowledge of the specific

strategies that are actually endorsed by health care professionals and the factors that

influence their use could be useful. Moreover, a number of factors might influence a clinician`s

decision regarding the use of hypnotic techniques (i.e. induction and suggestions), such as: (1)

his/her clinical orientation (e.g. altered state of consciousness and socio-cognitive

phenomenon), (2) years of practice with hypnosis, and (3) age of the patients. It can be the

case that the way clinicians describe hypnosis might have an influence in the selection of

hypnotic techniques. For example, a clinician endorsing an altered state orientation (e.g.

Bowers, 1966; Orne, 1959) might be expected to use techniques aiming to deep such a state,

whereas a clinician endorsing a social-cognitive orientation might not give such importance to

induction techniques since hypnotic response is a product of social influence and personal

abilities of the person hypnotized (i.e. alike other complex social behaviours: a product of

ability, attitude, belief, expectancy, attribution, interpretation of the situation; e.g. Barber,

1969; Kirsch, 1991; Sarbin, 1950;). Additionally, another factor that might also influence the

use and selection of hypnotic techniques is clinical experience with hypnosis. It might be

expected that as clinicians become more and more experienced certain techniques are more

endorsed than others; a number of strategies may be more often used has it might have a

greater chance of being most effective. Finally, age of young patients could influence likewise

the specific inductions and hypnotic suggestions selected. There is evidence supporting that

hypnotherapeutic inductions and suggestions should fit children`s developmental stage as well


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as social-emotional needs (Ollness & Kohen, 1996). Success work with children requires that

the professional adapt induction procedures and suggestions to the age of the child (Kohen in

Hammond, 1990; Olness & Gardner, 1988). Therefore, differences in the content of the

hypnotic sessions (e.g. different induction or suggestions) can be in part due to age of

participants, but also, due to clinicians` orientation and years of practice. It would be

interesting to further analyse the contribution of such factors on the use of specific hypnotic

techniques for the management of pain in youths.

3.4. Underlying mechanisms of hypnosis

Although 60 years of experimental research have clarified much of the nature of

hypnosis and the limits of its effects, its underlying mechanism remain, for the most part,

controversial (Barnier et al., 2008). On the one hand, hypnotic responses have been argued to

reflect relatively mundane psychological processes, such as expectancy, and then require no

special or additional explanation (e.g., Braffman & Kirsch, 2001; Sarbin, 1992, 1993; Spanos,

1986; Wagstaff, 1981, 1998), and on the other hand, it has been argued that hypnotic

responses reflect a fundamental transformation in cognitive processing (e.g., Hilgard, 1974,

1992; Kihlstrom, 1997, 1998, 2003; Woody & Bowers, 1994), giving special attention to the

exaggerated phenomenology considered the hallmark of hypnosis (Barnier et al., 2008).

Examples of exaggerated phenomenology are related to straightforward verbal

communications from the hypnotist, disruptions of personal agency and transient delusion

about the source and reality of their experiences. These two qualities, which Kihlstrom calls

experienced involuntariness bordering on compulsion and conviction bordering on

delusion, have remained central to definitions of hypnosis (Barnier et al., 2008). A number of

psychological factors (e.g., hypnotizability, response expectancies, imaginative involvement,

absorption, attitudes) have been proposed as relevant to explain the occurrence of hypnotic

behaviour (e.g., Barber, 1969; Braffman & Kirsch, 1999; Council et al., 1986; Henry, 1985;


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Kirsch, 1985; Milling et al., 2006; Patterson et a., 1997; Spanos, 1986); however there is not a

consensus on which of them is more important if any, or whether an interaction among

several is central. The identification of the key factors, not just psychological, but also

biological and social that can predict individual`s response to hypnosis would allow to have a

better understanding of hypnosis processes and responses.

Socio-cognitive research proposes that hypnotic responding is a product of expectancies

(Barber, 1969; for modern analyses, see Braffman & Kirsch, 2001; Kirsch, 1995, 1997, 2001),

and that expectancies are the sole proximal determinant of hypnotizability (Braffman & Kirsch,

1999; Gandhi & Oakley, 2005; Kirsch, 1985; Lynn et al., 2008; Kirsch, 2001). Expectancies are

defined as specific expectations for non-volitional outcomes (Kirsch, 1991, 1995), which reflect

automatic processes that directly cause expected outcomes. Accordingly, a variety of hypnotic

responses can be altered by manipulating people`s expectancies; i.e. typical hypnotic

responses can easily be altered by providing subjects with expectancy-altering information

(Kirsch, 1991). Consequently, expectancies about being hypnotized are important for its

confirmation, contrarily to its violation as advocated by the Discrepancy-Attribution Theory

(Barnier et al., 2008). However, the role of expectancy in hypnotic response is still in debate.

For example, very recently, it has been suggested that there is a complex relationship between

hypnosis and expectation, which is hardly reciprocal (Lifshitz et al., 2012). The former authors

also claimed that response-expectancies are likely insufficient to improve responsiveness to a

suggestion to override a deeply-ingrained automatic process. On addition, the empirical study

of expectancies has been extensively using a type of methodology (i.e. assessment after the

person is exposed to the hypnotic procedure) that may lead to overvalue the role of

expectancies. According to Kirsch (1991), the measurement of expectations before induction

fails to find strong relationships between expectations and responsiveness. Nevertheless, the

assessment of expectancies after hypnosis can contribute to the fact that the person is fully

aware of the benefits achieved via hypnosis, and positive results obtained thought hypnosis


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may, thus, motivate and make the person more receptive for the assessment. Future research

is warranted to investigate expectancies controlling for order (counterbalance assessment),

and test its predictive value in explaining hypnotic response (since it has been argued to be a

determinant of hypnotic response). Furthermore, the subjective experience related to

hypnosis has received little attention (Barret, 2007; Pekala & Kumar, 2000) and perhaps not in

the most appropriate manner (Barret, 2007; Woodard, 2003). Accordingly, a comprehensive

hypnotic responsivity assessment methodology should be able to assess hypnotism (according

to Pekala, the term hypnosis is reserved for the state, while hypnotism is reserved for the

production, for the study and use of suggestions with the state of hypnosis presumably being

present).


II. OBJECTIVES


OBJECTIVES

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In this work we focused on migraine pain at a cognitive and psychophysiological level, as

well as on the use of hypnosis for the management of pain. As evidenced by the literature,

chronic pain has been associated with cognitive biases and enhanced electrodermal activity to

pain material. Although, little is known about a potential conditioning or sensitization to

emotional material in migraineurs, as in chronic pain in general, it could be the case that

emotional stimuli also produces similar psychophysiological effects as to pain-related stimuli.

Additionally, on a cognitive level, pain-related and emotional stimuli may lead to a memory

bias. Hence, these factors could contribute to the maintenance and exacerbation of migraine.

Additionally, hypnosis seems to be a good therapeutic tool to intervene in pain memories

aiming to change not only the sensorial qualities of pain, but also the perception of such an

experience (affective and cognitive qualities). Hypnosis has been used as a pain control

technique worldwide by health professionals both with adults, children and adolescents,

proving positive results. Hypnotic responsiveness (i.e., response to hypnotic suggestions),

appears to depend on a number of factors; clarification of potential contributors is of central

interest to those involved in the management of chronic pain.

The main objectives of this doctoral dissertation were to:

1. Analyse the relationship between migraine and electrodermal activity, testing the

evidence of a highly specific conditioning to pain-related and negative emotional

material in migraineurs, and study whether there is a cognitive biases (i.e. memory

recall) in migraineurs

2. Study hypnosis in the management of chronic pain. Specifically the objectives

were to:

2.1. Evaluate the use and effects of hypnosis in the management of pediatric

chronic pain. That is: a) systematically review the use of hypnosis in children with

pain problems and the importance of one of the most widely studied predictors of

hypnotic response in child hypnosis; i.e. hypnotizability, and b) examine the


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frequency of use of specific hypnotic techniques (i.e. inductions and suggestions),

and whether they vary as a function of age of patients, and theoretical orientation

and years of experience with hypnosis of health care professionals.

2.2. Examine the use of hypnosis in adults. That is: a) test the value of expectancies

in hypnotic responsiveness (following a phenomenological perspective)


III. METHOD


METHOD

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In this section, we will briefly describe the methods used within each study, a full

description can be found in each article included in this dissertation.

In study I, we conducted an experiment comparing electrodermal activity and memory

recall to different words (i.e. pain-related, emotional and neutral) between migraineurs and

headache-free controls. In study II, we conducted a review on randomized control trials (RCTs)

on the use of clinical hypnosis in the management of chronic pain in children and adolescents

looking for evidence of its effectiveness as a pain control technique. In study III, we conducted

an online survey in order to gather information on the use of hypnotic inductions and

suggestions in the management of pediatric chronic pain. In study IV, we conducted an

experiment assessing the role of expectancies on phenomenological experience of hypnosis

(i.e. altered state of consciousness and hypnoidal state).

We have used a wide array of questionnaires to assess the variables of interest in each

of our studies. A complete description of each one of them is beyond the objectives of this

work, and so we decided to just list them in a table along with their references, addressing the

interested reader to look for specific descriptions in each one of the papers included in this

dissertation. Since study II and III were a review and an online survey, respectively, and were

not included in Table 3.

1. Participants

Three samples participated in our studies. First, a convenience sample of adults (N=66;

35 migraineurs and 31 headache-free controls; study I) who voluntarily agreed to participate in

an experiment on migraine. Those in the migraine group complied with the criteria of the

International Headache Society for the diagnosis of migraine with or without aura

(International Headache Society, IHS, 2004). The second sample consisted in 35 health

professionals who voluntarily agreed to participate in a study about the use of clinical hypnosis

in the management of pediatric chronic pain (study III). Inclusion criteria for this study were to


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32 | P a g e

have experience: (1) in clinical research on this topic (at least, being the rst author of 1 paper

or the co-author of 2 papers on the use of hypnosis in pediatric chronic pain) or (2) in clinical

work (at least, 2 years of experience working in the context of pediatric chronic pain). The third

sample was composed by 152 students of Psychology (study IV). Finally, the other paper

included in this dissertation were based on a specific review technique; i.e. a systematic review

(study II).

2. Procedures

Specific procedures for the experiments conducted are described within the papers

included in this dissertation, and will be not specifically presented here due to their diversity

and for a matter of brevity and limitation and economics of space. We do describe the review

procedures in order to clearly differentiate those that were used, granted that they do follow

different objectives. Finally, we also summarize the procedure used to collect information

from healthcare professionals in relation to the use of hypnosis in pediatric chronic pain

management.

In study II, we conducted a systematic review, which has been defined as a critical

assessment and evaluation of all research studies that address a particular clinical issue. As

such, we used an organized method of locating, assembling, and evaluating the literature on

the use of hypnosis in the management of chronic and procedure-related pain in children (a

complete description and key words used are reported in our article included in this

dissertation).

In study III, in order to gather information on the use of clinical hypnosis with young

chronic pain patients, we developed a survey (in English) in collaboration with clinicians and

researchers from The Milton H. Erickson Institute of Rottweil (Germany), and also experts

using hypnosis. The final version of the survey included 89 questions and was divided in three

sections: (1) demographic and descriptive information about the clinician; (2) clinical and


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33 | P a g e

research experience information about the respondent; and (3) information about the use of

hypnosis with children and adolescents with chronic pain. The survey had to be answered on-

line (a complete description of how this was conducted is reported in our article included in

this dissertation).

3. Measures

For sake of brevity, we summarize the measures in the following Table 3.

Table 3. Variables and measures of studies I and IV

Studies Variables Measures

Study I

Electrodermal activity

Pain descriptors

Pain intensity

Headache impact

Psychological distress (anxiety, depression)

Pain fear cognition (catastrophizing)

Personality dimensions

Memory recall

Amplitude of skin conductance response (microSiemens, S)

McGill Pain Questionnaire (MPQ)

Numerical Rating Scale (0-10)

Headache Impact Test (HIT-6)

Hospital Anxiety and Depression Scale (HADS)

Pain Catastrophizing Scale (PCS)

Zuckerman-Kuhlman Personality Questionnaire

Recall of words after the experiment (immediately or delay)

Study IV

Expectancies

Hypnotic phenomenology

Beliefs and attitudes about hypnosis

Anxiety

Depression

Pre-assessment form of PCI-HAP1

Phenomenology of PCI-HAP

VBAHS-C2

Zung Self-Rating Anxiety Scale (Zung)

Centre for the Epidemiological studies-Depression (CES-D

1Phenomenology of Consciousness Inventory Hypnotic Assessment Procedure (PCI-HAP); 2Valencia Scale of Beliefs and Attitudes about Hypnosis-client version (VBAHS-C)


IV. RESULTS


RESULTS

37 | P a g e

Study I

Tom-Pires, C and Mir, J (in press). Electrodermal responses and memory recall in

migraineurs and headache-free controls. European Journal of Pain

Study II

Tom-Pires, C and Mir, J (2012). Hypnosis for the management of chronic and cancer

procedure-related pain in children. International Journal of Clinical and Experimental

Hypnosis 60: 4, 432-457

Study III

Tom-Pires, C, Sol, E, Racine, M, de la Vega, R, Castarlenas, E, Jensen, MP, Mir (2014).

Use of hypnotic techniques in children and adolescents with chronic pain: do age of

patients, and years of practice and theoretical orientation of clinicians matter?

Submitted to International Journal of Clinical and Experimental Hypnosis

Study IV

Tom-Pires, C, Ludea, MA and Pires, CL (in press). Expectancies and hypnotic

responsiveness: an experimental design flaw revealed. International Journal of Clinical

and Experimental Hypnosis


1. Study I: Electrodermal responses and

memory recall in migraineurs and

headache-free controls


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Electrodermal responses and memory recall in migraineurs and headache-free controls

Catarina Tom-Pires and Jordi Mir

Unit for the Study and Treatment of Pain - ALGOS

Research Center for Behavior Assessment (CRAMC)

Department of Psychology and

Institut dInvestigaci Sanitria Pere Virgili

Universitat Rovira i Virgili

Catalonia (Spain)

Corresponding author: Jordi Mir, Departament de Psicologia; Universitat Rovira i Virgili;

Carretera de Valls, s/n; 43007 Tarragona; Spain

[email protected]

Running head: Electrodermal responses and memory recall in migraineurs

Category: original article

Funding sources: This work has been partly funded by a grant awarded to Catarina Tom-Pires

by the Fundao para a Cincia e a Tecnologia (FCT, Portugal; SFRH/BD/36330/2007), the

Ministerio de Educacin y Ciencia y Ciencia e Innovacin (project references: SEJ2006-

15247/PSIC and PSI2009-12193PSIC), the Fundaci La Marat de TV3, RecerCaixa and the

Agncia de Gesti dUniversitats i de Recerca, Generalitat de Catalunya (2009 SGR 434).


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ABSTRACT

Background: Chronic pain patients show increased peripheral activity when exposed to stimuli

relevant to their pain problem. It has been suggested that in migraine there is a highly specific

conditioning or sensitization to pain stimuli. The aims of this study were to analyse whether

migraineurs (1) are not only sensitive to pain-related stimuli but also to other negative

emotional stimuli, and (2) show a memory bias for pain stimuli, when compared to headache-

free controls. Methods: 66 adults participated in the study (X= 27 years; SD= 7). They observed

30 words (pain or negative emotional or neutral) in a pseudo-randomized order. Subsequently,

participants were asked to recall the words presented during the trial. Results: Skin

conductance responses (SCRs) induced by pain descriptors and emotional words were very

similar to each other and significantly larger than those induced by neutral words; however

there were no differences between both groups in SCRs. Significant differences in immediate

memory recall were found between the two groups: migraineurs recalled more emotional

words than controls. Conclusions: The findings suggest that in migraine, not only pain-related

but also negative emotional stimuli, may pose a threat. These outcomes may have therapeutic

implications as interventions could target problematic pain-related memories that influence

migraine pain perception and pain-related physiological responses.

Keywords: electrodermal activity, memory recall, migraine, pain descriptors, emotional

migraine triggers


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INTRODUCTION

Migraine episodes have been suggested to be related and somewhat maintained by

highly specific conditioning or sensitization to pain-related stimuli. Sensitization to these

stimuli would occur as a result of the additional significance that they acquire from repeated

associations with the patients internal pain experience (Jamner and Tursky, 1987). However,

highly and unique specific conditioning to pain-related stimuli is still a debatable question

(Knost et al., 1997; Larbig et al., 1996). For example, Bonnet and Naveteur (2006) found that

larger skin conductance responses were also induced by negative emotional words unrelated

to pain. In migraine, pain is a high involving experience, mainly processed in cortical zones

devoted to the emotive and affective aspects of nociception (de Tommaso et al., 2005). Thus,

it might be that not only pain-related stimuli enhance peripheral activity but also negative

emotional words may exert such effect. Emotional stimuli and also emotional states, as

negative affect, may act as migraine triggers (Janseen, 2002; Puschmann and Sommer, 2011).

To this point, no study has analyzed whether negative emotional stimuli unrelated to pain

may, in fact, induce similar reactions as pain-related stimuli would do in migraineurs. Learning

about if and how stimuli, other than pain-related ones, result in migraine episodes would help

to understand better migraine pathophysiology and improve preventive and palliative

interventions for migraine-related pain.

It has been demonstrated that chronic pain patients selectively recall pain-related

words (Pearce et al., 1990) and display selective attention towards pain-related material (Liossi

et al., 2011). Information processing in both attention and memory for pain-related stimuli is

not only associated with pain but also seems to be dependent on the emotional state of

patients and on trait predisposition to fear of pain (Asmundson et al., 1997; Keogh et al.,

2001). Thus, certain emotional states and internal personal characteristics of patients, like

anxiety and pain catastrophizing, may be associated with memory biases for pain and


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sustained migraine episodes. Although of therapeutic interest, there is not any study looking

into these issues in migraineurs.

Electrodermal activity (EDA) has been suggested as a useful predictor of sensitivity to

pain (Dowling, 1982), reflecting the reactive component of the pain experience (Fowles, 1980).

EDA reacts to pain both in healthy volunteers (Baltissen and Boucsein, 1986) and chronic pain

patients (Peters and Schmidt, 1989). In their seminal work, Jamner and Tursky (1987) reported

that skin conductance responses to pain words were significantly larger in migraineurs than in

headache-free controls; neutral, emotional pain-unrelated or body-related stimuli have failed

to produce the same psychophysiological effects in chronic pain patients (Flor et al., 1997). In

this work, we studied EDA to test the following hypotheses: (1) migraineurs will be more

sensitive than headache-free controls not only to pain-related stimuli, but also to negative

emotional stimuli; (2) migraineurs will show a memory bias for pain stimuli by recalling more

pain-related words than other types of words; and (3) memory biases to pain stimuli will be

related to emotion, and cognitive-related variables as anxiety, depression, and pain

catastrophizing in migraineurs.

METHOD

Participants

Documents

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